HEART OF KENT HOSPICE
Preston Hall
Aylesford
Kent
ME20 7PU
Please complete and return by email to [email protected]
APPLICATION FORM FOR POST OF:
………………………………………………
PROPOSED HOURS: (PLEASE CIRCLE) Full time
Part time
Job share
Flexi-bank
Other
Declaration: Data Protection Act (1998) I understand and agree that the information contained on
this form may be held on my HR File and recorded onto the Hospice Database during my employ at
Heart of Kent Hospice. In the event of unsuccessful application it will be destroyed within 6 months
from the date of interview.
Surname:
Dr / Mr / Mrs / Miss / Ms
Forename(s):
Telephone: Work:
Address:
Home:
Mobile:
Email address:
National Insurance Number:
Former Name(s)
Next of Kin:
Address:
Telephone: Work:
Home:
FURTHER PERSONAL INFORMATION
Please  as appropriate
Do you have a valid British Driving Licence?
Is it subject to any endorsements?
Do you require any reasonable adjustments to be made to enable you to attend
the selection process? (If yes please advise accordingly)
Do you require any reasonable adjustments to be made to enable you to carry
out the job for which you have applied? (If yes please advise accordingly)
Yes
Yes
 No
 No
Yes
Yes

No
 No




Page 1 of 5
July 2016
PRESENT OR MOST RECENT EMPLOYMENT
Name of Employer
Post Held
Grade and
Salary
From
To
Brief Nature of
Duties
Reason for
Leaving
PREVIOUS EMPLOYMENT - Please provide your full employment and/or training history, including an
explanation of any gaps between periods of employment or training (Please continue on a separate sheet if
required
Name of Employer
Post Held
Grade and
Salary
From
To
Brief Nature of
Duties
Reason for
Leaving
Page 2 of 5
July 2016
Please state here (and on a separate sheet if you wish) why you are applying for this post and any further
information that you wish to be considered
EDUCATION AND TRAINING
Schools
From
To
Examination and Results
College / University
From
To
Courses and Results
Further Education / Training
From
To
Courses and Results
Please state membership of professional bodies and qualifications you hold, or are studying for with
dates and registration number if applicable. For those applying for nursing posts, please state your pin
number and expiry date.
RECRUITMENT SOURCE
Please indicate how you became aware of this opportunity e.g. Details of Job Board, Advert Publication, Word
of mouth etc.
Page 3 of 5
July 2016
SOCIAL ACTIVITIES/INTEREST
EMPLOYMENT/CHARACTER REFERENCES
We seek to validate a minimum of three years continuous employment and/or training. Additional references
may be required to provide adequate assurances.
Please provide the contact details of referees as required One must be your present or most recent
employer and they should be able to provide information relating to your experience and qualifications for
this position.
May your referees be approached prior to shortlist? (Please circle) Yes / No
Please give name, title and address, including
email address:
Referee 1.
Please give name, title and address, including
email address:
Referee 2.
Page 4 of 5
July 2016
THIS SECTION MUST BE FULLY COMPLETED
REHABILITATION OF OFFENDERS ACT 1974
Posts at Heart of Kent Hospice are exempt from the provisions of the Rehabilitation of Offenders Act
1974. Applicants are therefore not entitled to withhold information about certain convictions. The
amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions
are “protected” and are not subject to disclosure to employers and cannot be taken into account.
Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure
and Barring Service website www.gov.uk/government/collections/dbs-filtering-guidance
Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as
defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)?
Yes

No

If you have answered Yes to the above, full details must be provided below. Continue on a separate
sheet if required.
Please note that the existence of previous conviction(s) caution(s) or bind over(s) will not automatically
disbar any candidate. Each case will be carefully considered on its individual merits.
FITNESS TO PRACTICE
Are you currently the subject of any investigation or proceedings by any body having regulatory
functions in relation to health/social care professionals in the UK or any other country?
Yes

No

If you have answered Yes, please provide details on a separate sheet.
Have you ever been disqualified from the practice of a profession or required to practise it subject to
specified limitations following a fitness to practice investigation by a regulatory body, in the UK or
another country?
Yes

No

If you have answered Yes, please provide details on a separate sheet.
ADDITIONAL INFORMATION
Have any of your relatives or friends been a patient at Heart of Kent Hospice?
Yes / No
Have you suffered bereavement in the past 12 months? Yes / No
If yes, what was the relationship to you:
First available date for employment or length of notice required by present employer:
DECLARATION
I certify that, to the best of my belief, the information I have supplied is true and complete. I understand
that any false information or failure to disclose fitness to practice proceedings, criminal convictions or
prosecution pending, may disqualify me from employment or render me liable to summary dismissal.
SIGNATURE:
DATE:
Page 5 of 5
July 2016
HEART OF KENT HOSPICE
EQUAL OPPORTUNITIES MONITORING
Heart of Kent Hospice recognises and actively promotes the benefits of a diverse workforce and is committed
to treating all employees and job applicants equally, without discrimination on the grounds of gender, sexual
orientation, marital or civil partner status, gender reassignment, race, colour, nationality, ethnic or national
origin, religion or belief, disability or age. In order to develop Equal Opportunities at Heart of Kent Hospice a
system of monitoring has been set up and to assist with data collection all applicants are requested to
provide the following information. The monitoring form will be detached from your application and the
information will not be taken into account in employment decisions, but used only for monitoring purposes.
How would you describe your nationality and/or ethnicity? (Please tick appropriate boxes throughout)
White:  British
 Irish
 Any other white background
(please specify)
Mixed race:
 White and Black Caribbean
 White and Black African
 White and Asian  Any other mixed background
(please specify)
Black or Black British:
 Caribbean
 African
 Any other Black background
(please specify)
Asian or Asian British:
 Indian
 Pakistani
 Bangladeshi
 Any other Asian background
(please specify)
Chinese or Other Ethnic Group:
 Chinese
 Other Ethnic Group (please specify)
What is your gender? (please tick)
What is your age?
(please tick)

Male
16-17
51-60
Female
 18-21
 61-65
Do you consider yourself to have a disability?

Prefer not to say

 22-30  31-40 
 66-70  71+ 
 Yes
41-50

 No
If yes, please state nature of disability:
The Equality Act 2010 defines disability as “A physical or mental impairment which has a substantial and long-term adverse
effect on a person’s ability to carry out normal day-to-day activities”
How would you describe your sexual orientation?
Heterosexual
Gay


Bisexual
Lesbian


(please tick)
Prefer not to say

Please describe your religion or other strongly-held belief
I would describe my religion or belief as:
I have no particular religion or belief:

Page 6 of 5
July 2016